I adopted an electronic medical record in 1995 and began electronic prescribing in 2009. I electronically review the patient’s records from the hospital and the imaging centers. All of this effort takes time, but improves care. My associates are like minded, but they are both younger and married to husbands that are professionals. If the reimbursement model for caring for the chronically ill does not improve, I will probably continue to work, but my associates will simply drop out.

Dr. Goodman points out some very interesting ideas, but the best method of reducing unnecessary care is to pay someone with advanced expertise more to provide the care needed. Nurse and physician extenders are fine for simple problems, but they are not capable of handling the complexity of 15 medications in a chronically ill person. Service follows reimbursement and once the reimbursement falls below the cost of delivery, the service stops.

I think that Dr. Goodman has to much faith in Medicare Advantage programs. Many of these simply increase the cost of delivery of care by shifting administrative burdens on to the physician. I have never had a CT of the chest or sinuses denied, but my staff and I spend needless time obtaining approval. The same issue exists for a multitude of medications. This is one aspect were traditional Medicare allows for delivery of care in a more efficient manner.

While it may be overly simplistic, it seems that the solutions lie in having more of us with more skin in the game, return insurance to the concept of what one cannot afford to cover. In ’75, costs were less out of control when we were all paying about a third of our costs out of pocket.

At the clinic where I work, we only see Medicaid. The vast majority of families I see have cell phones, iPods, latte’s in hand and promise their kids a happy meal if they’re good. From my observations we aren’t subsidizing health care for the poor so much as we are subsidizing other non-essentials. I rarely see a family that couldn’t afford a $5-10 copay.

I am also a doctor on the dole. My wife has been on dialysis for almost 12 years, with medicare paying out over 3/4 million dollars and counting. In my vision of health care, I should be paying at least $20,000 annual deductible before the government paid a dime.

Of course if we were all paying more of our share, we would find much more cost saving innovation. I met a dialysis patient who applied and became his own medicare supplier. At the end of two years, after covering his supplies and billing Medicare for each dialysis treatment, he had 20,000 in his account.

It’s unconscionable that my daughter who works for minimum wage is paying into Medicare to support millionaires on this system. We can’t continue attempts correct perceived injustices by passing on massive debts to our children. And if we find it is acceptable to go into debt when it is a matter of life and death and righting wrongs, then we may as well as plan on joining Greece in total financial insolvency.

Fix the payments system. After that, systems for “coordinating” care will likely develop that take both supply realities and patient preferences into account.

I am beginning to sound like an old record. Quality of care, utilizing technology only when medically necessary, and injecting a good dose of honesty and integrity in the delivery of care is what will save our system. Yes, there should be care that is acceptable for all of us, but if there are those who want extra bells and whistles, let them have it if they will pay for it out of pocket. If primary care is to survive, you will see a big increase in personalized or concierge medicine; if there are more cuts in Medicare reimbursement, you will see more physicians opting out. Then where will the patients go? Why can’t reasonable people address all aspects, not merely the ones that effect their monetary gain.

The logic usually goes something like this, “The fire in our building is a huge issue, and we have to hold someone accountable for it right now!” And then the person goes through a process of creating a rubric of checklists that are supposed to point to the guilty party. They don’t worry about the fact that the building is burning to the ground.

I do believe, though, that John offers some valuable comments here that cannot be brushed aside: for purely political reasons that go back to the founding of Medicare, that program has never been allowed to be a clinically or economically prudent purchaser of health care, as Ken, no doubt would agree.

At a recent Cato Institute meeting I was taken to task by some proponents of the single-payer for not using my forum to advocate for the single payer program (as if I naturally owed that to anyone). My response was exactly that in our political system such a program probably would not be allowed to be a good purchaser and coordinator of health care. Whereupon I read a blog smearing me for serving on the board of a Medicaid managed care company that does try to coordinate care — perhaps not as well as ideally we would like to, but we do try.

Over the years I have always leaned towards Paul Ellwood’s and Alain Enthoven’s vision of a combination of managed competition among insurers and managed care by insurers, ideally with delivery systems that are clinically integrated — like Geisinger or Mayo or Kaiser. Some of them might employ carve outs wehere that makes sense.

In any event, I think John should pull back the arrest warrant for Ken.